Don’t be that therapist!

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January 02, 2015 at 1:01 PM

In our clinical practice and training programs, we use a highly structured and directive treatment approach. The reason for this is that you (the therapist) are the professional, and your client is contracting you for services so that s/he can achieve his/her treatment-related goals. You are supposed to be the one with the expertise to deliver the service effectively and efficiently.

This is not to say that the client has no choice or input. To the contrary, the whole point of treatment is to accomplish the client’s goals, so it’s essential to learn what the client’s goals are. However, that does not mean that the therapist should rely on the client for technical guidance on how the treatment should be conducted.

If you went to a doctor who asked, “What diagnosis would you like today?” and then after you responded, asked, “So what treatment would you like? And what dose?”  Well... you wouldn’t go back to that doctor, would you? You want your doctor to pay attention to what you say, but also to make his/her own diagnosis and recommendations, and discuss those with you.

So don’t be that therapist.

Yet therapists routinely do this. We ask, “What do you want to talk about today?” or variations such as “What’s on your mind?” We follow the client’s lead (we do respond), and see where the session goes. And when it’s time to do trauma resolution work, we ask, “What memory would you like to work on?”

The problem with just doing what your client wants to do, or talking about whatever your client happens to bring up, is that there is no informed consent. Your client would be making decisions and guiding the treatment without the benefit of your professional advice. This is wrong, and denies your client the opportunity to make informed decisions regarding his/her treatment. Your client should know what you know, before s/he decides.

That means that when your client tells you the presenting problem, or what memory s/he wants to work on, it's up to you to figure out what you believe will be the best way to help. Then give your client adequate information – including the reason for your recommendation, as well as alternative options with pros and cons – to make an informed decision.

For example, many trauma therapists report encouraging their clients to choose which trauma memory to work through, with the rationales that (a) “clients know what they’re ready for” and (b) “letting clients choose is empowering” which supposedly enhances the therapy relationship (Greenwald et al, 2014). However, clients may not in fact know what they’re ready for, and could easily become overwhelmed by attempting trauma resolution work with a difficult memory before they are prepared to cope with it (Briere & Scott, 2012; Greenwald, 2013; Herman, 1992). Then the therapy relationship is damaged – not enhanced – because the therapist failed to provide adequate professional guidance. Indeed, in the good old days when clients were routinely over-exposed to their trauma memories (with therapeutic intent, via implosion or flooding therapy), dropout rates of 35% were not uncommon (Solomon, Gerrity, & Muff, 1992).

A broader example is the use (or non-use) of a treatment contract. Presenting a convincing rationale for treatment activities (Messer & Wampold, 2002), and agreement on treatment goals and tasks (Horvath & Greenberg, 1994) are complex interventions and difficult to implement, requiring an advanced level of skill (Mallinckrodt & Nelson, 1991). Yet coming to a shared understanding of the source of the clients problems, and agreement about what to do about them, provides the foundation for the therapy alliance, one of the key elements of successful treatment (Norcross, 2010). Even so, many therapists never get around to providing a clear case formulation to their clients, much less developing an explicit agreement with the client to pursue a specific plan of action on that basis.

It's not enough to just do what your client tells you to do, or to just “follow the client’s lead.” Your job is to provide information and recommendations based on your professional knowledge and judgment; then your client can make informed decisions, relying on the benefit of your expertise. Much of the art of therapy is in helping your client to understand his/her problems with a perspective that will lead him/her to make beneficial choices.

References

Briere, J., & Scott, C. (2012). Principles of trauma therapy: A guide to symptoms, evaluation, and treatment, 2nd ed. Thousand Oaks, CA: Sage.

Greenwald, R. (2013). Progressive counting within a phase model of trauma-informed treatment. New York: Routledge.

Greenwald, R., McClintock, S. D., Bailey, T. D., & Seubert, A. (2014). Treating early trauma memories reduces the distress of later related memories. Manuscript submitted for publication.

Herman, J. L. (1997.) Trauma and recovery. NY: Basic Books.

Horvath, A. O., & Greenberg, L. S. (Eds.) (1994). The working alliance: Theory, research, and practice. New York: John Wiley & Sons.

Mallinckrodt, B., & Nelson, M. L. (1991). Counselor training level and the formation of the psychotherapeutic working alliance. Journal of Counseling Psychology, 38, 133-138.

Messer, S. B., & Wampold, B. E. (2002). Common factors are more potent than specific therapy ingredients. Clinical Psychology Science and Practice, 6, 21-25.

Norcross, J. C. (2010). The therapeutic relationship. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy, 2nd edition, pp. 113-141.

Solomon, S. D., Gerrity, E. T., & Muff, A. M. (1992) Efficacy of treatments for posttraumatic stress disorder. An empirical review. Journal of the American Medical Association, 268, 633-8.



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Posted by Molly Wolf on
A few months ago, I would have read this post and disagreed with it. However in the last few months I have learned a lot about EMDR, and that technique uses the approach you discuss in this post. Now that I know better, I couldn't agree more with this post. The problem comes down to education, I think. In graduate programs, we are not taught specific therapeutic techniques, but ARE taught to let the client lead. So until a few months ago, I thought that was the only right way to help. I was wrong, and I'm glad you are starting this discussion.
Posted by Ricky Greenwald on
Molly, I am expecting plenty of disagreement :^)

The therapist providing some type of case formulation, treatment plan, and guidance in the treatment is possible and desirable even within psychodynamic and humanistic treatment approaches. And these are among the "common factors" that lead to better treatment outcome, across treatment orientations.

I am going even further and advocating a structured, directive approach, which is not consistent with some treatment orientations.
Posted by Jamie Marich on
Great post Ricky, thank you! I rarely reply on blogs get this one has been sticking with me the last few days, so I wanted to chime in with my two cents:

Here are my thoughts on the issue--- presented here as a modified excerpt from my book "Trauma Made Simple" (2014):

Carl Rogers provided a helpful metaphor to describe empathy (Raskin & Rogers, in Corsini, 2000; p. 135): "Being empathetic reflects an attitude of profound interest in the client’s world of meanings and feelings. The therapist receives these communications and conveys appreciation and understanding, assisting the client to go further or deeper. The notion that this involves nothing more than a repetition of the client’s last words is erroneous. Instead, an interaction occurs in which one person is a warm, sensitive, respectful companion in the typically difficult exploration of another’s emotional world. The therapist’s manner of responding should be individual, natural, and unaffected. When empathy is at its best, the two individuals are participating in a process comparable to that of a couple dancing, with the client leading and the therapist following."

Jamie's thoughts: I know that this dance metaphor makes many therapists nervous, especially those of us with the mentality that a patient is sick and needs the therapist’s guidance. So why on earth would be let the client lead? As a former ice dancer and ballroom dancer who happens to be female (and thus, the party who is traditionally led), I have some insights to offer. When you fight where your leading partner wants to take you, the dance will be atrocious from a performance perspective; at best, it just won’t feel as right or as magical as if you let the natural flow unfold. There is nothing wrong with being led, even if everything in your personality structure resists it. In training and practice, there is nothing wrong, as the female partner, with stopping the dance from time to time if something doesn’t feel right and having a discussion with your partner about what needs to change. A communicative, healthy dance partner will listen to your concerns and make adjustments. These training habits, combined with a certain natural chemistry, are why partners like Fred Astaire and Ginger Rogers, Jane Torvill and Christopher Dean, and Margot Fonteyn and Rudolf Nureyev made magic and went down as artistic legends. As therapists and helpers, may we be open to the same suggestion that being led is a necessity for the magic to happen! Yet we don't have to thrown out our training, our competence, and our directive guidance when something feels wrong.
Posted by Ricky Greenwald on
Jamie, thank you for taking the time to comment. And in case you were wondering, it's fine to mention your book. I'm hoping to get this blog upgraded so that commenters can link to their own web sites. Meanwhile, mentioning your work in the text of the comment is a good solution.

Carl Rogers was one of the pioneers of the common factors research, which discovered the importance of therapist factors/behaviors such as empathy, warmth, and positive regard. Among those common factors that improve therapy outcomes are developing a shared understanding with the client about what's going on with them, and what to do about it. Also particular therapy activities such as EMDR (shall we mention your other book, Jamie?) require a high degree of therapist guidance. So some therapist guidance is essential regardless of therapy approach (and more common in certain approaches).

Along with the lovely dance metaphors, what you raise is that there is a time and way to follow as well as a time and way to lead. Following the client's lead helps to develop relationship and trust, gives us a better chance of learning what is important to the client, and facilitates client initiative. This is true even in the structured, directive approach I use.
Posted by Bonnie Roberts on
Lovely metaphor and important points from everyone. The best therapy is, essentially, collaborative. Client is expert on their life and we have other expertise to offer. Thanks for posting.
Posted by Ricky Greenwald on
Exactly.
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